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Indian Health Services

Transition to Office of Management and Budget (OMB) Reimbursement

Eureka | Fairfield | Redding | Santa Rosa

Overview Rates Payment Methodology

Visit Types Exceptions to OMB Rate PHC Enhanced Benefits

Authorization Requests Billing Information

Claim Form / Format Code Set Other Health Insurance Electronic Claims / Paper Claims

Agenda

Overview


Overview

Effective 1/1/2018, Managed Care Plans are required to reimburse Indian Health Service (IHS), Memorandum of Agreement (MOA) 638 Clinics for eligible services at the applicable Office of Management and Budget (OMB) encounter rates. This is an updated presentation as of September 2020 with increased rates.


Overview - Rates

The OMB encounter rates are all-inclusive for eligible services. There are 2 applicable encounter rates.2020 outpatient per visit rates, lower 48 states:

Excluding Medicare

Medicare Primary $336.74

$479

Effective Date for Calendar Year 2020:The rates will be effective for services provided on/or after January 1, 2020.


Overview – New Payment Methodology

Services that are included in the Medi-Cal benefit and billed to PHC will be reimbursed on a fee-for-service basis at the OMB rate.

Providers continue to be eligible for our Quality Improvement Program (QIP).

Visit Types


Visit Types

Medical Health Visit• Face-to-face encounter occurring at a clinic or center between an American

Indian Health Program recipient and physician, physician assistant, nurse practitioner, nurse midwife or visiting nurse in certain circumstances.

Mental Health Visit• Face-to-face encounter between an American Indian Health Program recipient

and a psychiatrist, clinical psychologist, clinical social worker, or other health professional for therapeutic mental health services.

• Note: Bill mild-to-moderate Mental Health services to PHC, not Beacon.

Ambulatory Visit• Face-to-face encounter between an American Indian Health Program recipient

and a health care professional other than a physician or mid-level practitioner which is included in California’s Medi-Cal State Plan.

• Note: Bill Vision services to PHC, not VSP.

One OMB encounter rate payment will be allowed, per day, per the following categories. A maximum of three OMB encounter payments are allowed per day, as long as there is only one in each of the categories.


Exceptions to OMB Rate

Non-medical Transportation Non-emergency Medical Transportation

Pharmacy Adverse Childhood Experiences (ACEs)


PHC Enhanced Benefits

PHC contracts with clinics to provide certain services to adults that are not covered by Medi-Cal or are considered subject to optional benefits exclusion.

The PHC enhanced benefits do not qualify for OMB reimbursement.

Services are reimbursed per contract.

Bill services on a separate claim.

Acceptable billing types for PHC enhanced benefits:

UB-04

837I Format

CMS-1500 Form

837p Format

Authorization Requests


Authorization Requests

Note: A RAF is not required for services that qualify for OMB reimbursement

A TAR is required for

OMB Ambulatory encounters

PHC enhanced benefits services

A TAR is not required

Medical OMB encounters

Mental Health OMB encounters

A TAR is required for

A TAR is notrequired for

Billing Information


Claim Form/Format

Submit OMB line with revenue code, procedure code and modifier, if appropriate.

Add information line with traditional CPT or HCPCS Code.

Submit information line with zero billed amount.

Bill OMB rate(s) using UB-04 Form or 837I Electronic Format. This is consistent with billing to the State since October 2017.


Information lines are required to document the visit. Enter Procedure Code and charges of zero.

Example UB-04 Form

*Do not use a decimal point.


Discussion: In October 2017, DHCS required a new code set. It assumed the provider was also billing for the MCP differential rate.

Code Set

If you believe your claim was processed incorrectly, please reach out to our Claims Department. We want to address issues as they arise.

The Code Set for OMB services is attached to this webinar.

The 01/01/2018 Code Set reflects the complete OMB rate.

There will be no additional billing to the State.


Other Health Insurance - Medicare

Providers can bill concurrently to Medicare and PHC.

Bill PHC for OMB rate using the appropriate revenue code and Medicare-specific HCPCS code.

Medicare EOMB is not required for reimbursement by PHC.

PHC will reimburse up to the allowable California modified rate of $336.74.


Bill PHC for OMB rate using the appropriate revenue code and procedure code.

Primary EOMB is not required for reimbursement from PHC.

PHC will reimburse the full OMB rate of $479.00.

Other Health Insurance - Commercial


Trauma Screening

G9919Once in 11 months per provider for children 0-20 yrs.One in a lifetime per provider for members 21 years and older

G9920Once in 11 months per provider for children 0-20 yrs.Once in a lifetime per provider for members 21 years and older.

Developmental Screening

96110Payable per year of age (0 to <20) without TARMay only be used with one of the DHCS approved screening tools.Autism only screening; socio-emotional screens and other must use 96110.KX.

96110.KXPayable per year of age (0 to <20) without TAR.May be used for screening that does not include one of the nine screening tools approved by DHCS.

Adverse Childhood Experiences (ACES)


Electronic Claims

It is recommended that all providers who currently submit claims electronically, submit test claims, even if currently in production. This is not a requirement.

We encourage you to use electronic billing.

Contact InformationPHC EDI Enrollment & TestingInformation Technology DepartmentPhone: (707) 863-4527 | Fax: (707) 863-4390Email: [email protected]

mailto:[email protected]


Paper Claims

To avoid processing errors when submitting paper claims, we suggest configuring your system to fill in a number 1 in the Unit Field for all lines.

If you cannot fill in the units of service, please send the paper claim for special review to:

PHC/Medi-CalP.O. Box 1368Suisun City, CA 94585-1368Attention: Nicholas Thompson


Resources

Monday - Friday8 a.m. - 5 p.m.

Claims Telephone Support(707) 863-4130

Contact your Assigned PR Representative

PHC Online Serviceshttps://provider.partnershiphp.org

Partnership HealthPlan of Californiawww.partnershiphp.org

Our Mission: To help our members, and the communities we serve, be healthy.

https://provider.partnershiphp.org/

Indian Health Services (IHS) Clinics

Billing for OMB Services

Revenue Code Procedure Code and Modifier Description

0520 T1015 PHC Primary Medical, per visit

0520 G0466 Medicare Crossover Claims - New Patient

0520 G0467 Medicare Crossover Claims - Established Patient

0520 G0468Medicare Crossover Claims - Initial Preventive Physical Exam, (IPPE) or

Annual Wellness Visit (AWV)

0420 T1015 PHC Primary Ambulatory Visit - Physical Therapy

0430 T1015 PHC Primary Ambulatory Visit - Occupational Therapy

*0440 T1015 PHC Primary Ambulatory Visit - Speech Pathology

*0470 T1015 PHC Primary Ambulatory Visit - Audiology

*0510 T1015 PHC Primary Ambulatory Visit - Podiatry

0520 H0047 PHC Primary Ambulatory Visit - Drug and Alcohol

0520 92004 Optometry Services, per visit - New Patient

0520 92014 Optometry services, per visit - Established Patient

*0940 98940PHC Primary Ambulatory Visit - Chiropractic manipulative treatment.

Spinal, one to two regions


Spinal, three to four regions


Spinal, five regions

2101 97810PHC Primary Ambulatory Visit - Acupuncture one or more needles.

Without electrical stimulation initial 15 minute service

2101 97811PHC Primary Ambulatory Visit - Acupuncture one or more needles.

Without electrical stimulation. Each additional 15 minute service

2101 97813PHC Primary Ambulatory Visit - Acupuncture one or more needles. With

electrical stimulation. Initial 15 minute service

2101 97814PHC Primary Ambulatory Visit - Acupuncture one or more needles. With

electrical stimulation. Each additional 15 minute service

0900 G0469 Medicare Crossover Claims - Mental Health Visit – New Patient

0900 G0470 Medicare Crossover Claims - Mental Health Visit – Established Patient

0561 T1015 - AG Modifier Medical Other Health Visit - Psychiatrist

0561 T1015 - AH Modifier Medical Other Health Visit - Clinical Psychologist

0561 T1015 - AJ Modifier Medical Other Health Visit - Clinical Social Worker

0561 T1015 - HR Modifier Medical Other Health Visit - Marriage and Family Therapist

*Subject to Optional Benefits Exclusions

MEDICAL SERVICES - Bill PHC

AMBULATORY SERVICES - Bill PHC

MENTAL HEALTH SERVICES - Bill PHC

April 2018

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